HIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION

Transcription

1 HIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION PLEASE ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE (N/A) Applicant Name: HIRED AUTO INFORMATION Coverage Subject to Audit 1. Why is hired auto coverage being requested? 2. Do you lease, hire, rent or borrow any vehicles from others?... Yes No What is the average term of the lease? Is there a written agreement?... Yes No Does it include a Hold Harmless agreement and/or Additional Insured clause?... Yes No Provide a copy of the agreement. 3. Do you hire independent contractors?... Yes No If yes, do you require certificates of insurance?... Yes No Provide a copy of the contract. 4. If owner/operators are leased, will they be scheduled on your policy?... Yes No If yes, provide a copy of the agreement you use. 5. Do you use sub-haulers?... Yes No If yes, provide cost of hire... $ Provide a copy of the contract. 6. Do you lease, hire, rent, or borrow any vehicles from others without drivers?... Yes No Will they be scheduled on the policy?... Yes No What is the average term of the lease? 7. What is your cost to lease, hire, rent or borrow vehicles? With drivers:... Without drivers:... Estimated cost of hired autos: This year:... Last year: Is Hired Auto Physical Damage coverage desired?... Yes No If yes, average value of auto hired? 9. How many autos are hired on average within a twelve (12) month period? CA-APP-12 (1-17) Page 1 of 5

2 10. How many hired autos are in the insured s possession at any one time? 11. What type of vehicles do you lease, hire, rent or borrow? Truck-Tractors: % Trailers: % Heavy & Extra Trucks: % Pickup trucks or Vans: % Private Passenger Cars: % 12. At any time will your employees, subcontractors, or owner/operators lease vehicles in your name?... Yes No If yes, explain: 13. Do you arrange or dispatch loads for others, not including your own hired truckers?... Yes No Please explain: Are you named on the Bills of Lading?... Yes No Annual number of Truckers: Loads: 14. Do you have motor carrier brokerage authority?... Yes No If yes, is the brokerage authority held under the same name and motor carrier number as your trucking operation?... Yes No What is your motor carrier brokerage number? Whose name appears on the Bill of Lading as the carrier? What is your brokerage revenue for the most recent twelve (12) months? Estimated next twelve (12) months? 15. Do you understand that we may audit your records for Hired auto exposure, which might result in an additional premium?... Yes No NON-OWNED AUTO INFORMATION Coverage Subject to Audit 16. Why is non-ownership liability coverage being requested? 17. What types of non-owned autos will be used in your business? Total number of non-owned autos used:... How will they be used? 18. How often are non-owned autos used in your business? Daily Weekly Monthly Other: Estimate the number of hours per month: Estimated annual mileage for use of all non-owned autos: 19. Do any employees use their autos in your business?... Yes No If yes, what limit of liability insurance are they required to maintain? Do you require evidence of insurance?... Yes No 20. Will you use non-owned autos other than those owned by employees?... Yes No If yes, describe the relationship: 21. Total number of employees: Total number of officers and partners: 22. If a social service operation, indicate the total number of volunteers furnishing autos in your operation:... Maximum number of volunteers at any one time:... How will they use their vehicles? 23. Are volunteers required to have their own insurance?... Yes No Minimum limits required: CA-APP-12 (1-17) Page 2 of 5

3 24. Do you obtain motor vehicle records for all employees and volunteers?... Yes No 25. Do you understand that we may audit your records for Non-Owned auto exposure, which might result in an additional premium?... Yes No FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY, OH, OK, OR, RI, TN, VA, VT or WA.) NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. CA-APP-12 (1-17) Page 3 of 5

4 NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. CA-APP-12 (1-17) Page 4 of 5

5 NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. APPLICANT S NAME AND TITLE: APPLICANT S SIGNATURE: (Must be signed by an active owner, partner or executive officer) PRODUCER S SIGNATURE: DATE: DATE: AGENT NAME: AGENT LICENSE NUMBER: (Applicable to Florida Agents Only) Note to General Agent: If hired auto coverage is provided, notify the Premium Finance Company of the audit required. CA-APP-12 (1-17) Page 5 of 5